Transcript The Patient is Not our Enemy”

The “Seven Pillars” Approach:
Improving Patient Safety and Decreasing
Liability Through Transparency
Timothy McDonald, M.D., J.D.
© 2008 The Board of Trustees of the University of Illinois
The Problem
 Institute
Medicine report To Err is Human: Building a
Institute ofof
Medicine:
Making Matters
1999
report
that
Safer Health System
Worse
shook the medical
worldof Silence: The Untold Story of the Medical
 Wall
Mistakes that Kill and Injure Millions of Americans by
Rosemary Gibson and Janardan Prasad Singh
McDonald
© 2008 The Board of Trustees of the University of Illinois
The UIC experience prior to 2004
 “Deny and Defend” approach to all patient harm
 Loss of patient and family trust
 Minimal internal or external transparency
 Non-existent learning from harm events or “claims”
 Progress in patient safety stymied
 Occurrence reports – only 1,500 per year
 No resident physician occurrence reports
 Resident Patient Safety education confined to orientation
 Inconsistent participation on hospital-wide committees
McDonald
© 2008 The Board of Trustees of the University of Illinois
A “less than honest” approach when
things went wrong years ago
 The beginning circa 2000
 The K.C. case, COO of sister hospital
 Preoperative testing prior to plastic surgical procedure
 Evening before surgery - lab tests done
 WBC <1,000 (normal value 4-12,000)
 Only Hgb & Hct checked on day of surgery
 Repeated CBC (complete blood count) postop
 WBC <600
 Called as critical result to the unit – reported to “Mary, RN”
 Never found out who “Mary, RN” was
McDonald
© 2008 The Board of Trustees of the University of Illinois
A “less than honest” approach when
things went wrong
 Patient discharged from hospital on post-op day 3
 Died 6 weeks later from leukemia
 Physician colleagues/friends reported death to Risk
Management
 Legal Counsel & Claims Office were approached with
a plan for “making it right”
 All attempts to disclose, apologize, or provide remedy
were rejected by University
McDonald
© 2008 The Board of Trustees of the University of Illinois
What about an Extremely Honest
“Principled Approach”?
 Barriers
McDonald
 Benefits
© 2008 The Board of Trustees of the University of Illinois
Taking a “Principled Approach”
 Barriers
 Lack of skill
 Loss of job
 Reputation
 “Shame and blame”
 Loss of control
 Loss of license
 Fear of lawyers,
litigation
 Non-standard process
 Money
McDonald
 Benefits
 Maintain trust
 Learn from mistakes
 Improve patient safety
 Employee morale
 Psychological wellbeing
 Accountability
 Money
 Less litigation
© 2008 The Board of Trustees of the University of Illinois
Adding to the lack of confidence
Oct 2008, the defense rests…….
John Stalmack article “It Is a Mistake to
Admit a Mistake,” Vol. 6, Issue 8, Chicago
Hospital News, 7 (October, 2008)
McDonald
© 2008 The Board of Trustees of the University of Illinois
Fears
 Based on two Illinois Appellate Court cases
 Occurrence reports are discoverable
 Without proper By-Laws and Committee structure
investigations are discoverable
 All process improvements are discoverable
 Lawyers consistently advise physicians to not
participate
McDonald
© 2008 The Board of Trustees of the University of Illinois
2005 UIC Board approves
“Patient Safety-Transparency” program
 Comprehensive
 Integration of safety, risk, quality and credentials
 Linkage to claims and legal – deal with the fears
 Longitudinal patient safety education plan
 UGME
 GME
 CME
McDonald
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars:
A Comprehensive Approach to Adverse Patient Events
Unexpected Event reported to
Safety/Risk Management
Data Base
No
“Near misses”
Patient Harm?
Yes
Patient
Communication
Consult Service
24/7
Immediately
Available
Consider “Second Patient”
Error Investigation
Hold bills
No
Inappropriate
Care?
Yes
Process Improvement
Activation of
Crisis
Management
Team
Full Disclosure with
Rapid Apology and Remedy
McDonald
© 2008 The Board of Trustees of the University of Illinois
A Comprehensive Response to Patient Incidents:
The Seven Pillars.
McDonald et al Quality and Safety in Health Care, Jan 2010
 Reporting
 Investigation
 Communication
 Apology with remediation
 Process and performance improvement
 Data tracking and analysis
 Education – of the entire process
McDonald
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars:
A Comprehensive Approach to Adverse Patient Events
Unexpected Event reported to
Safety/Risk Management
Data Base
No
“Near misses”
Patient Harm?
Yes
Patient
Communication
Consult Service
24/7
Immediately
Available
Consider “Second Patient”
Error Investigation
Hold bills
No
Inappropriate
Care?
Yes
Process Improvement
Activation of
Crisis
Management
Team
Full Disclosure with
Rapid Apology and Remedy
McDonald
© 2008 The Board of Trustees of the University of Illinois
Occurrence reports: if you don’t
know about it you can’t fix it
McDonald
© 2008 The Board of Trustees of the University of Illinois
ACGME core competencies
 Patient Care
 Medical Knowledge
 Practice-Based Learning & Improvement
 Interpersonal and Communication Skills
 Professionalism
 Systems-based Practices
McDonald
© 2008 The Board of Trustees of the University of Illinois
Aggregate resident physician
occurrence reporting data
McDonald
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars:
A Comprehensive Approach to Adverse Patient Events
Unexpected Event reported to
Safety/Risk Management
Data Base
No
“Near misses”
Patient Harm?
Yes
Patient
Communication
Consult Service
24/7
Immediately
Available
Consider “Second Patient”
Error Investigation
Hold bills
No
Inappropriate
Care?
Yes
Process Improvement
Activation of
Crisis
Management
Team
Full Disclosure with
Rapid Apology and Remedy
McDonald
© 2008 The Board of Trustees of the University of Illinois
The Patient Communication
Consult Service
 PCCS – immediately available
24/7
 Current options
 Empowerment
 Participation
 Expectations
 Physician involvement
 Patient-family involvement
McDonald
© 2008 The Board of Trustees of the University of Illinois
Communication is the key
McDonald
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars:
A Comprehensive Approach to Adverse Patient Events
Unexpected Event reported to
Safety/Risk Management
Data Base
No
“Near misses”
Patient Harm?
Yes
Patient
Communication
Consult Service
24/7
Immediately
Available
Consider “Second Patient”
Error Investigation
Hold bills
No
Inappropriate
Care?
Yes
Process Improvement
Activation of
Crisis
Management
Team
Full Disclosure with
Rapid Apology and Remedy
McDonald
© 2008 The Board of Trustees of the University of Illinois
UHC Derived Safety and Quality Measures
2010 Quality Index Report
450
400
350
300
Safety
250
Core Measures
Readmission
200
150
100
50
0
2008
2009
2010
Calendar Year
McDonald
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars:
A Comprehensive Approach to Adverse Patient Events
Unexpected Event reported to
Safety/Risk Management
Data Base
No
“Near misses”
Patient Harm?
Yes
Patient
Communication
Consult Service
24/7
Immediately
Available
Consider “Second Patient”
Error Investigation
Hold bills
No
Inappropriate
Care?
Yes
Process Improvement
Activation of
Crisis
Management
Team
Full Disclosure with
Rapid Apology and Remedy
McDonald
© 2008 The Board of Trustees of the University of Illinois
Claims experience
McDonald
© 2008 The Board of Trustees of the University of Illinois
ROI for institutions:
Improving safety reduces liability
“Reducing Patient Safety Incidents by 10
decreased claims by 3.9.”
http://www.rand.org/pubs/technical_reports/TR824.html
McDonald
© 2008 The Board of Trustees of the University of Illinois
AHRQ/Seven Pillars Project focus
 Patient Safety first
 Improved communication
 Reduce preventable injuries
 Compensate patients/families fairly and timely
 Reduced medical malpractice liability
McDonald
© 2008 The Board of Trustees of the University of Illinois
Pillar #6 Data
McDonald
© 2008 The Board of Trustees of the University of Illinois
What next
 10 hospitals in Chicago
 8 hospitals in South Carolina with SCHA
 2 hospitals in New Jersey
 Collaboration with other grantees in Colorado,
Washington, Massachusetts, Texas
 Begin to work with Policy Makers on removing
barriers and creating incentives
McDonald
© 2008 The Board of Trustees of the University of Illinois
Next steps
 Commitment: Leadership
 Medical Centers
 State Societies
 Insurers







Gap Analysis
Identify teams
Metrics
Timeline for implementation
Implement
Measurement
Feedback
McDonald
© 2008 The Board of Trustees of the University of Illinois
Questions
McDonald
© 2008 The Board of Trustees of the University of Illinois